Synopsis While transiting the St. Lawrence Seaway en route from Sarnia, Ontario, to Montreal, Quebec, the ENERCHEM REFINER was under the conduct of the second officer with the assistance of the third officer. A course alteration was not carried out on time and the vessel ran aground near buoy D-57 off Thompson Island, at about 1250 Eastern daylight time. Ce rapport est galement disponible en franais. 1.0 Factual Information 1.1 Particulars of the Vessel 1.1.1 Description of the Vessel The ENERCHEM REFINER is a tanker, with the bridge, accommodation, and engine-room located aft of the 12port and starboard cargo tanks. It operates seasonally and is laid-up during the winter months. 1.2 History of the Voyage The vessel was chartered unexpectedly and, on 30 March 1998, departed Sarnia, Ontario, en route to Montreal. A replacement master and chief officer were hired as the vessel's regular officers were on training before the start of their operational season. The vessel was operated in compulsory pilotage waters of the St. Lawrence Seaway, but was not subject to compulsory pilotage based on criteria contained in Article 4.1 of the Great Lakes Pilotage Regulations. The navigation and the pilotage was carried out by the navigating personnel on the bridge for the duration of the transit. At 1200,[3] after exiting the Snell Lock, the bridge was crewed by the second officer (2/O), who had the conduct of the vessel and was performing pilotage duties. The third officer (3/O) was assisting the 2/O by performing the duties generally carried out by the officer of the watch (OOW). The wheelsman was at the helm. The vessel was proceeding at eight knots, and the visibility was known to be one and one-half to two miles. The master was resting below-deck. While on a course of 061 and approaching buoy D-64 (see Appendix A), the 2/O was using binoculars to visually identify the next set of ranges in order to ensure the next alteration of course. The 3/O was engaged in verifying the position of recently established floating aids vis--vis known landmarks. The vessel's speed over the ground in the channel was about 10 knots; there was no other traffic in the vicinity. The vessel passed buoy D-64 at approximately 1245 and proceeded past the course alteration point. The wheelsman noticed that the vessel had passed the turning point but did not communicate this information to the officers because he believed that the responsibility for course alteration rested with them. By the time the 2/O realized that the vessel had overshot the alter-course position, the vessel was outside the navigable channel, having passed buoy D-59 to port at approximately 1248. The 2/O immediately drew the 3/O's attention to this. The 3/O then ordered hard-to-port helm while the 2/O took charge of the engine controls. The port engine was placed on full astern in an attempt to return the vessel to the channel. These efforts were unsuccessful. The vessel continued outside the channel and grounded at 1250, on a shoal south of buoy D-57 on a heading of 311, in position latitude 4504' 07N and longitude 07431' 08W. The channel remained unobstructed for the transit of other traffic. Ballast was pumped out; some 500 tonnes of cargo were discharged into the barge McASPHALT 401. The vessel was eventually refloated at 1230 on 4 April 1998 with the assistance of the tugs JOHN SPENCE and JERRY NEWBERRY. The vessel proceeded on its own power to an anchorage off Cornwall where, following inspection, permission was granted for the vessel to transit the Seaway to undergo repairs. 1.3 Injuries to Persons 1.4 Damage to Vessel and Environment An underwater inspection of the hull was carried out following the grounding. Damage was sustained to the bilge and bottom plating. Several scratches and scuff marks along her bottom plating were observed. The vessel had sustained a 110-cm long crack in way of frame 63, plate B on the port side. No pollution was observed or reported. 1.5 Certification 1.5.1 Certification of Vessel The vessel was equipped and operated in accordance with existing regulations for its trade. The vessel had a valid International Safety Management (ISM) certificate issued by Det Norske Veritas in December 1997. 1.5.2 Certification and History of Personnel The master was properly certificated and had many years of experience in the navigation and pilotage of vessels in these waters. He was not part of the bridge team at the time of the grounding and was acting as a replacement for the regular master. The relief master was hired for a week. He had no previous training in Bridge Resource Management (BRM) nor was he familiar with Electronic Chart Systems (ECS). He had not received training related to the application of the Safety Management System (SMS) of the ship. The 2/O and the 3/O were properly certificated to perform their duties. Each was appropriately qualified to carry out pilotage for this sector of the Seaway. The 2/O has been carrying out pilotage duties since 1978 and the 3/O since 1970. Neither had previous training in BRM or in the use of ECS. 1.5.3 International Safety Management Code (ISM Code) The International Safety Management Code (ISM Code)was adopted in 1993 by the International Maritime Organization (IMO) as Resolution A.741 (18). It has been made mandatory subsequent to this occurrence by virtue of the entry into force on 1 July 1998 of Chapter IX, Management for Safe Operation of Ships, of the International Convention for the Safety of Life at Sea(SOLAS). The ISM Code provides an international standard for managing and operating ships safely and for preventing pollution. The International Chamber of Shipping (ICS) publication Guidelines on the Application of the IMO International Safety Management Code is designed to assist companies in the development of an SMS. Article 6 deals with resources and personnel. The guidelines suggest that records of crew certification be maintained by the owner and that, in assigning crew to vessel, consideration be given to ensure the following: that the master is properly qualified for command and is fully conversant with the company's SMS; that the master is given the necessary support so that the master's duties can be safely performed; that the crew is capable of safely executing normal operational and emergency-related tasks; that the crew is given proper familiarization of the vessel and its equipment; and that training needs of the crew are identified. Following an ISM audit, the ENERCHEM REFINER was issued an ISM certificate in December 1997, towards the end of the operating season, some four months before the occurrence. No training was planned over the winter lay-up period. 1.5.4 Crew Training In 1997, the regular crew had been given three days' in-house training on the ship's SMS, which included ISM-related training. The relief master was not conversant with the above standards nor was he familiar with the ship's SMS. The navigating officers had received a one-and-one-half-hour introductory briefing on the ECS and had communicated to company officials the need for further in-depth training on the ECS. The system was new and had not been configured properly which led them to question the accuracy of the ECS. Consequently they were unwilling to trust the system. According to company policy, only senior personnel, i.e. the master and the chief officer, were given BRM and ECS training with the understanding that they, in turn, would provide on-the-job training to the rest of the crew. There is no regulatory requirement for such training. The regular master and chief officer had not received ECS training during the winter months, but were receiving training at the time of the occurrence. The navigating officers who formed part of the regular crew hired by the owners had not received training on the ECS. 1.6 Weather and Current Conditions At the time of the occurrence, the weather was good, but visibility was reduced to approximately 1.5 to 2 miles in mist. At this time of year, the current in the area is known to be approximately two to three knots, follows the direction of the channel, and in this instance was setting in the same direction as the vessel. 1.7 Communication and Decision Making Communication between the 2/O and the 3/O with respect to the navigation of the vessel was minimal. There was no language barrier. The 2/O was responsible for making decisions. He was supported by the personnel on watch and by navigational information from Vessel Traffic Services by very high frequency (VHF) radio. 1.8 Navigation Equipment The vessel's navigation equipment included the following: two radar sets, neither fitted with automatic radar plotting aid (ARPA) capabilities; one global positioning system (GPS); an ECS[4] capable of providing a wide range of information, such as ship's heading, course made good, speed, way point and cross track information, depth information, and alarms to meet changing navigational needs; a gyro compass with repeaters appropriately positioned; a speed log, depth sounders, and VHF and medium frequency (MF) radios; and Canadian Hydrographic Service (CHS) chart No. 1413, which was in use at the time of the grounding. No equipment malfunction was reported. 1.8.1 Bridge Layout The bridge was comprised of a console located to the starboard of the centre line against the bridge front bulkhead which included engine controls. The starboard radar was positioned to the right of the console. The ECS was positioned aft of the starboard radar between the radar and the chart table. It was mounted on a swivel permitting the display to rotate some 180. The steering position was located along the centre line of the vessel, aft and to port of the console. The port radar was positioned behind the bridge front bulkhead and to port of the centre line. 1.9 Navigation in Pilotage Waters In accordance with company policy, two officers were on the bridge in confined pilotage waters, the 2/O performing pilotage duties and the 3/O performing OOW duties. In accordance with the ISM Code, the company's standing instructions to navigation personnel make reference to the Regulations for Preventing Collisions at Sea(COLREGS) and to the Recommended Code of Nautical Procedures and Practices. Their application meant the following: that the 3/O was to cooperate closely with the 2/O and maintain accurate position and movement checks; that the presence of the 2/O on the bridge did not relieve the 3/O from his duties and obligations to ensure safety of the ship; that, when in doubt as to the 2/O's actions or intentions, the 3/O seek clarification from the 2/O; and that, when the 2/O relinquishes the handling of the vessel underway, he clearly indicate this fact to the 3/O. 1.10 Conduct of Navigation As the vessel approached Cornwall Island, the 2/O was positioned on the starboard side of the wheelhouse, between the radar and the ECS, while the 3/O was positioned behind the radar on the port side. During the transit, the 3/O was in charge of plotting the vessel's position and/or cross-referencing with the chart in use. The last position plotted was some 25 minutes before the occurrence. The 2/O referred to the radar to monitor the vessel's progress. He was identifying the leading markers ahead. As the buoy system had been put in place for the season a week before the occurrence, the 3/O was also busy verifying the positions of the floating aids. 1.11 BRM and BRM-Related Issues The essence of BRM is the effective use of all available resources to complete an operation safely. BRM addresses managing attention, operational tasks, stress, attitudes, and risks. BRM recognizes that individual, organizational, and regulatory factors are involved in safe and effective operations. Optimizing the management of these elements will have a direct effect on four factors critical to the successful outcome of any operation, namely, recognizing and defining the nature of the problem encountered (situational awareness); reflecting on and regulating one's own judgements or decisions (metacognition); involving others in the problem-solving process (shared mental models); and understanding tasks to be performed, their priorities, and required and available resources (resource management). Successful BRM programs address several key areas, such as team building and maintenance, communication and decision-making processes, workload management, situational awareness, watch systems, and working environments. 1.11.1 Team Building and Maintenance Characteristics of individual team members are important. However, in a team, work is shared, tasks are performed in a more timely and effective manner, and a higher level of performance is achieved than that by the best individual working alone. Research has demonstrated that it is during the team formation process that patterns of communication and interaction are established.[5] Once established, the process continues and leads to activities that can maintain patterns of effective (or ineffective) group communication. 1.11.2 Communication and Crew Decision-Making Processes Crew decision making is managed decision making. In this instance, the 2/O is responsible for making decisions but is supported by input from the crew, both on the bridge and from shore (e.g. traffic services). This requires a group climate that encourages participation and the exchange of information. Poor communication can result in crews not sharing a common understanding of a situation, or in a misunderstanding of the 2/O's intentions. 1.11.3 Workload Management The tasks essential for safe navigation of the vessel are allocated to different persons best equipped or experienced to perform them so that no member of the bridge team carries a workload that is beyond his/her capabilities. 1.11.4 Situational Awareness Situational awareness is the accurate perception of the factors and conditions that affect a vessel and its crew during a defined period of time.[6] More simply stated, it is knowing what is going on around you. The safety of the voyage depends on the level of situational awareness of the individual who has the conduct of the vessel. The ease and effectiveness of communication is a fundamental factor in maintaining optimal situational awareness. It is essential that each member of the bridge team does everything feasible to support the person in charge to maximize his level of situational awareness. 1.11.5 Watch Systems Normal (sea) watches on the bridge were four-hours-on watch and eight-hours-off, except when all hands are required to transit the locks. However, while transiting the St. Lawrence Seaway, the vessel adopted a dual-watch system composed of an officer in charge of pilotage assisted by an additional officer. The additional officer is assigned to navigation, cross-referencing the vessel's position, and assisting the person in charge in the pilotage of the vessel. The wheelsman executes helm orders and ensures that the courses ordered are steered in accordance with the orders of the officer in charge. 1.11.6 Working Environment on the ENERCHEM REFINER The working environment on the bridge was less than formal and the 2/O and 3/O had sailed together for many years on this vessel. There was no explicit arrangement between the 2/O and the 3/O. Furthermore, company procedures did not call for a clearly defined arrangement. There was no agreement as to who should give alter-course orders to the wheelsman. During previous transits of the area, the 2/O gave these commands. 1.12 Work, Rest, and Sleep History 1.12.1 Second Officer (2/O) During the 72 hours prior to the occurrence, the 2/O was operating under a four-hours-on and eight-hours-off shift, with his duty hours being 0000 to 0400 and 1200 to 1600. The 2/O indicated that he had no problem sleeping. He indicated that he normally obtained a total of six to eight hours of sleep per day, a four- to five-hour sleep period in the early morning and a two-hour period in the evening. In the morning before the occurrence, he went to bed at 0430 and awoke at 0900. His 72-hour history is presented below: 1.12.2 Third Officer (3/O) The 3/O indicated that on average, he obtained a total of eight to nine hours of sleep per day during two sleep periods of approximately four hours each, one in the afternoon and one in the early morning. The night before the occurrence, he went to sleep at 0230 and woke up at 0630. 1.12.3 Wheelsman The wheelsman indicated that on average he slept a total of approximately 10 to 11 hours per day, 6.5 hours at night and 4.5 hours in the early evening. The night before the occurrence, he slept between 0415 and 1045. 1.13 Electronic Chart System (ECS) The chart information in the ECS presents navigational information in real time. The OOW must continuously analyse and evaluate the position of the ship, intended track, and manoeuvring characteristics in order to warn of approaching dangers. In addition, the ECS provides alerts and prompts for planned course alterations and many other sophisticated navigation and safety features, including continuous data recording for later analysis. A review of the ECS following the occurrence indicated the following: that the vessel position record data prior to the grounding was missing; and that the malfunction was attributable to the computer clock and the GPS time not being synchronized. The manufacturer reviewed certain software parameters and ensured that corrections will be made to avoid future malfunctions of the ECS data recorder.